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A crisis in nursing? Safe staffing is the key.

This week, i newspaper released a four-day report on “The Crisis In Nursing“. Last year the Health Ombudsman released a report “Care And Compassion“. Both of these reports both upset and frustrated me. On the one hand I, like every other person working in the health service, have seen sub-standard care, neglected patients and staff with poor attitudes. On the other hand, I believe that only a very small minority have “bad attitudes” and a lack of compassion at their core. Rather, short-tempers, lack of attention to detail and supposed nonchalance towards patient care are, I believe, symptoms of understaffing and high stress levels. Last year I wrote this article for Solidarity magazine on my own experiences. No patients, hospital trusts or staff members are mentioned by name, nor should they be identifiable within the context of this article.

Additionally, the unions’ recent response to the threats to the NHS, in the form of job cuts and the Health & Social Care Bill, have exceeded my expectations. Their campaigning and organising in the last 18 months has taken a very different direction from the largely “servicing” approach of previous years. I make reference to this in the italicised notes within the article.

The content of the recent Ombudsman’s report on care of the elderly in the NHS was, sadly, not a shock to me. All the scenarios described were similar to incidents I had witnessed or could easily imagine happening. But, contrary to what the report says, I do not believe that it is a universal problem with attitude towards the elderly, but that it is all, directly or indirectly, down to staffing.

The situation on my [former] ward is one that is mirrored across the trust, and indeed across the country. Low morale, high stress levels, short tempers and neglected patients all result from the fact that we do not have enough staff to provide complete and adequate care for our 26 very dependent patients. On a night shift, we have two Registered Nurses and two Health Care Assistants (unless we can “justify” a third HCA by proving that one or more patients are very restless and therefore safety will be compromised if they are not monitored one-on-one). So each qualified nurse is responsible for 13 patients. If one patient becomes seriously ill during the night, and needs constant attention from a trained nurse, the other is left with 25 patients. No one can argue that this is a safe nurse-to-patient ratio, and yet this is our norm, it’s deemed as acceptable, and is echoed across the trust. The RCN’s guidelines are that, on an acute adult ward, no Registered Nurse should be responsible for more than five patients on a day shift, and eight on a night. Californian recently nurses went on strike over nurse-to-patient ratios, and as a result were successful in getting legislation passed for safer staffing levels (one to five). This is not something I can see happening in the UK. There is no appetite for a fight, and even nurses who do long for change believe that they “cannot” strike, for fear of compromising patient care. [NB: This article was written before the pensions dispute which saw members in UNISON and Unite, along with a few other health unions, take industrial action. However, this was one day over pensions, and it was the minority of nurses who struck. Most trusts reported normal levels of service on 30th November. It would take more widespread, sustained action to secure any kind of guarantee of staff-to-patient ratios in law. This government is set on dismantling the NHS, not building it up and improving patient safety.]

Channel 4 is airing a Dispatches programme on 21st February [2011] about food and nutrition in hospitals. Patients and their relatives have gone on camera, detailing their “appalling” experiences of meals in hospitals and the lack of assistance given to those who cannot feed themselves. However, what is never taken into account in the hundreds of damning reports around nutrition in hospitals, is the fact that meal times are akin to a military operation in their complexity. On our ward, evening supper is particularly challenging: One staff member has to push the hot food trolley around and serve the dinners (we don’t have a domestic for this), and ideally should have another member of staff to help take dinners to the patients. One person then needs to give out puddings and one person to do a tea round. There will always be at least a couple – but sometimes as many as six or eight – patients who need to be fed (or at least prompted/encouraged to eat, either because of reluctance, apathy or dementia). Then, all those patients who are on food record charts need to have their charts filled in – accurately (type/amount of food, action taken if patient refuses food or is unable to take food orally). So really, for meal times to go smoothly, dinners to remain hot and all patients’ nutritional needs to be met, you ideally need at least eight staff, concentrating only on meal provision. On a late shift (when supper is served), we have four or five staff. Halfway through the meal, two qualified nurses have to start the drugs round. Add onto that the inevitable fact that several patients will need the toilet during the meal time, and that others may be confused and need to be monitored for safety, and you are realistically left with one or two people having to undertake the mammoth task of serving up three courses to 26 patients, ensuring that they are all well fed, and that everything is documented accordingly. You can see why staff become frustrated and patients go hungry – or have incontinence problems – at meal times, as it’s so often a choice between one or the other – dinner or toilet. Wet yourself or miss your dinner. What would you choose?

But despite these glaring issues, the staff rarely recognise that these problems are top-down, and could be remedied – or at least alleviated – by increasing levels of ward staff. If I bring up the subject of the impending cuts and reforms to the NHS, people are either oblivious or apathetic. I noticed from day one at my workplace that none of my colleagues seem politically aware or motivated, and most are concerned only with their own day-to-day existence. The idea of unions as a tool for change is alien to almost everyone I speak to – the union is there to represent us at sickness hearings, isn’t it? Unfortunately, the unions don’t do much to combat this mindset. Aside from a few recruitment stalls throughout the year, their presence is barely felt. Meetings are poorly advertised and there are few known stewards across the trust. We are threatened by massive job cuts, yet there has been little in the way of resistance or organisation to fight what is undoubtedly a huge threat to the safety and welfare of patients. [NB: UNISON has, in the last year, been at the forefront of the fight against the NHS Bill, and is a major player in the pensions dispute. However I still feel that there is a lot more work to be done on protecting – and preferably improving – terms and conditions, pay, pensions and the integrity of the NHS as a whole.]